Telehealth Technology-
The Future is Here
Charlie Mishek & Leah Fernandez
February 17, 2015
Telehealth
It’s Not about the Technology …
It’s About Expanding Access and Enhancing Treatment Services
Over half of the country’s land mass is designated as frontier or
rural
(NRHA, 2008; USDA, 2000)
Approximately one quarter of the U.S. population (62 million people) lives in
frontier/rural areas
16-20% of those individuals experience substance dependence, mental illness, or
co-morbid conditions
Minnesota
• 21.5K adults ages 18-64 with substance use
disorders will have coverage for substance use
treatment under Medicaid expansion
• 33K adults ages 18-64 with substance use
disorders will have coverage for substance use
treatment within the Health Insurance Exchange
• This represents a double in the estimated
prevalence within the existing eligible Medicaid
population (currently 60K).
Recovery and Resilience Oriented System of Care
ROSC: A PARADIGM SHIFT
Recovery-Oriented Systems of
Care (ROSC) shifts the question
from:
“How do we get the client into
treatment?”
to
“How do we support the process of
recovery within the person’s life and
environment?”
What is a ROSC?
Recovery-oriented systems
of care (ROSC) Is a process
of change through which
individuals improve their
health and wellness, live a
self-directed life, and strive
to reach their full potential.
CSAT, SAMHSA
Recovery-oriented systems of
care (ROSC) are networks of
formal and informal services
developed and mobilized to
sustain long-term recovery for
individuals and families
impacted by severe substance
use disorders. The system in
ROSC is not a treatment
agency, but a macro level
organization of a community, a
state or a nation.
William “Bill” White
One Answer- Telehealth Technologies
Telehealth
Clients’ and Providers’ Best Interests Expanding
Access
Enhancing
Treatment Services
The Difference
Telehealth
‘the use of telecommunications and
information technologies to provide access to
health information and services across a
geographical distance’
Telemedicine
‘use of medical information exchanged from
one site to another via electronic
communications to improve patient health
status’
(Institute of Medicine (IOM), 2012)
Types of Telecommunications
•
Synchronous communications
Videoconferencing
- Telephone -
•
Asynchronous Communications
-
•
Email Web-based programs
Some telehealth technologies include
both type of communications
(IOM, 2012)
Definitions
•
Originating Site
–
•
Where the
patient is located
the delivery of telehealth services where the
beneficiary (patient) is located at the time the
service is being rendered via a telecommunications
system occurs
Distant Site Practitioner
–
the practitioners at the distant site, away from the
beneficiary, who may furnish and receive payment
for covered telehealth services (subject to State law)
Types of Telehealth



Videoconferencing
Computer-based Interventions
Web
-

Web-Portals
-

Videoconferencing
Messaging (chat and email)
Telephone
-

Screeners
Support Groups
Virtual Reality/Video Games
Disease Management Programs
Continuing Care
Interactive Voice Response
Mobile Phones
-
Texting
Prevalence
Annually, 10 million
patients receive
telemedicine services
(IOM, 2012)
Systematic Review of
Videoconferencing Psychotherapy
•
Patients and providers perceived a strong therapeutic
alliance over videoconferencing
•
Studies that compared videoconferencing to in-person
psychotherapy reported similar satisfaction levels
between the conditions
•
high levels of satisfaction and acceptance with
telemental health have been consistently demonstrated
among patients across a variety of clinical populations
and for a broad range of services
(Backhaus et al., 2012)
Computer-Based
Interventions
Examples of Computer-Based
Interventions
•
CBT4CBT (Carroll et al., 2008)
–
–
•
TES [Therapeutic Education System] (Marsch & Bickel, 2004)
–
–
–
–
•
Outpatient clients
CBT + 6 computer modules on CBT
Community Reinforcement Approach + Incentives
HIV/AIDS Intervention-Opioid treatment clients (2004)
Outpatient Opioid Treatment- TAU + TES (2008)
Outpatient Treatment-2hrs per week of TES + TAU (2012)
Ondersma (2005/2007)
–
single-session computer-delivered MI intervention reduced drug
use among postpartum women
Remote Patient Monitoring (RPM)
Healthcare Provider
- Uses telehealth technologies to
collect medical data from patients in
one location and electronically
transmit that information to health
care providers in a different location.
Clients video
themselves taking the
breathalyzer
The Question-
The vital question for this field is not “Do computer-assisted
therapies work?” but…..
Which specific computer assisted therapies
• Delivered under what conditions
• To which population
exert effects that approach or exceed those of
standard clinician-delivered therapies”?
(Kiluk et al., 2011)
Web-Based Disease Management
Programs
•
Cancer
(Gustafson et al., 2005)
•
Diabetes
(Glasgow et al., 2005; Williams et al., 2007)
•
Heart Disease
(Verjejjden et al., 2004)
•
Mood Disorders
(Farvolden et al., 2005)
Web Screeners
Studies found that web screeners that
provided automated personalized
feedback impacted participants' behavior
more than those with non-personalized
feedback
(Bewick et al., 2008)
Use of the Telephone
Monitor/treat chronic mental & physical illness
– Smoking
(Stead, et al., 2006)
– Depression
(Simon, et al., 2000)
– Obsessive Compulsive Disorder
(Taylor, et al., 2003)
– Hypertension
(Bosworth, et al,. 2005)
– Diabetes
(Kim & Oh, 2003)
– Rheumatology problems
(Pal, 1998)
Telephone Continuing Care for SUDs
•
Telephone Monitoring and Adaptive Counseling (TMAC)
(McKay, 2004)
•
Focused Continuing Care (FFC) (Betty Ford Clinic)
•
Telephone Enhancement of Long Term Engagement (TELE)
(Hubbard et al., 2007)
•
Individual Therapeutic Brief Phone Contact (ITBPC)
(Kaminer & Napolitano, 2004) ADOLESCENTS
•
Telephone Case Monitoring (TCM)
(McKellar et al., 2012)
•
Telephone Continuing Care (TCC)
(Godley et al., 2010)
Privacy, Security, & Confidentiality
Issues with Telehealth
HIPAA
(Health Insurance Portability &
Accountability Act)
HITECH
(Health Information Technology for
Economic & Clinical Health Act)
Privacy Rule
(Standards for Privacy of
Individually Identifiable Health
Information)
42 CFR Part 2
(Substance abuse treatment)
The Regs
Privacy and Security Rules
Privacy & Security
Rules are Different
•
•
HIPAA Privacy Rules - What situations can
individual health information be disclosed, no
matter its format (oral, paper, or electronic)?
HIPAA Security Rules - How are disclosures in
electronic format made?
(Karasz et al., 2012)
New Ethical Dilemmas in the Digital Age
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Staff Usage
Use of technology
by counselors •
•
is increasing
presents unique
ethical dilemmas
(NBCC Policy, 2013)
Technology ‘Creep’
Lack of literature and research to
provide guidance
• Technology may be used as part of the
•
‘Therapeutic Exchange’
and then WHAT?
– Documentation of the exchange
– Guidelines for the exchange
(Gabbard et al., 2011; Mishna et al., 2012)
Some professionals are….
…ethically astute but
struggle to keep up with the technology.
…comfortable with
technology but less familiar
with ethical codes.
(Lannin & Scott, 2013)
‘Adapting to the
new culture wisely will necessarily
involve both understanding the
ethical principles themselves as
well as developing competence
in the technology of the
burgeoning digital culture.’
(Lannin & Scott, 2013)
Ethical Issues
Ethical Codes and Technology
• Ethics and Self Disclosure
•
–
•
Self Disclosure Definition/Guidelines
Self Disclosure and Social Media
Rural Examples
– Guidelines for Disclosure
–
Ethical Reasoning
• Liability Insurance for Social Media
•
Ethical Codes and Licensing Boards
have not caught up
with the TECHNOLOGY
In some cases … provide little guidance
Other boards may use existing laws and
investigate complaints on the grounds of:
•
•
•
•
•
•
Unprofessional conduct
Unethical conduct
Moral turpitude
Mismanagement of patient records
Revealing a privileged communication
Breach of confidentiality
(Cronquist & Spector, 2011; Spector & Kappel, 2012)
Ethical Codes Related to the Use of Technology
in Counseling/Therapy/Treatment
•
NAADAC (Association for Addiction Professionals)
•
National Board of Certified Counselors (NBCC)
•
American Counseling Association (ACA)
•
American Mental Health Counselor Association
(AMHCA)
•
American Association of Marriage and Family
Therapy (AAMFT)
•
National Association of Social Workers (NASW)
Ethical Concerns
related to
4 areas of telehealth technology
•
•
•
•
Informed Consent
Confidentiality/Privacy
Records & Data
Competency
(NAADAC Code of Ethics, Rev. March 28, 2011)
Questions?
Contact:
Leah Fernandez
651-431-2533
[email protected]
Charlie Mishek
651-431-5683
[email protected]